and the TOVA Overview of this Workshop Attention Disorders including ADHD Continuous Performance Tests CPTs and the TOVA Goals for this Workshop Promote EmpiricallyBased Assessment of attention and ID: 811865
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Slide1
Attention Deficit Hyperactivity Disorder and the T.O.V.A.
Slide2Overview of this Workshop
Attention Disorders, including ADHD
Continuous Performance Tests (
CPTs
) and the
T.O.V.A.
Slide3Goals for this WorkshopPromote Empirically-Based Assessment of attention and impulsivity
Improve the lives of children and adults ‘at risk’ for the diagnosis of ADHDImprove care for children and adults with attention
problems
Slide4Objectives of this WorkshopThe participant will learn about theDSM IV criteria for ADHD and limitations.Diagnostic procedures for attention problems.Treatment modalities for attention problems.
Use and interpretation of the T.O.V.A. in the diagnosis and treatment of attention problems.
Slide5Response Histogram Illustration 1
Slide6Response Histogram Illustration 2
Slide7Response Histogram Illustration III
Slide8Attention IAttention is best described as the sustained focus of cognitive resources while filtering or ignoring extraneous information. Attention is a very basic function that often is a precursor to many other neurological/cognitive functions. (Wikipedia)
Focused attention: This is the ability to respond discretely to specific visual, auditory or tactile stimuli.Sustained attention: This refers to the ability to maintain a consistent behavioral response during continuous and repetitive activity.
Slide9Attention IISelective attention refers to the capacity to maintain a behavioral or cognitive set in the face of distracting or competing stimuli. It incorporates the notion of “freedom from distractibility”.Alternating attention refers to the capacity for mental flexibility allowing individuals to shift their focus of attention and move between tasks having different cognitive requirements.
Divided attention is the highest level of attention and it refers to the ability to respond simultaneously to multiple tasks or multiple task demands.
Slide10Attention SpanAverage attention span for adults is 20 minutes.Hyper-focusing is the ability to narrow one’s world down to a task or experience. People often experience losing track of time during these periods.
Slide11TerminologyInattention, distractibility, impulsivity and hyperactivity- descriptive termsSymptom-complex- a cluster of symptoms
Attention Deficit Disorders (ADDs)- not diagnosticAttention Deficit Hyperactivity Disorder (ADHD)
a specific DSM IV diagnosis
a biologically-based psychological process
Target symptom
-
the focus of treatment
Slide12DSM IV Types of ADHDPredominantly Inattentive Type (314.00) Predominantly Hyperactive-Impulsive Type (314.01)
Combined Type (314.01) ADHD Not Otherwise Specified (314.9)
Slide13The Diagnostic Criteria for ADHD IThe Predominantly Inattentive Type (314.00) must have six or more of the following symptoms:
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, etc.;Often has difficulty sustaining attention;Often does not seem to listen to what is being said;
Often does not follow through on instructions and fails to finish schoolwork, chores, or work (but not due to oppositional behavior or failure to understand instructions);
Often has difficulty organizing tasks and activities;
Often avoids or strongly dislikes tasks requiring sustained mental effort;
Often loses things necessary for tasks or activities;
Often easily distracted by extraneous stimuli; and
Often forgetful in daily activities
Slide14The Diagnostic Criteria for ADHD IIThe Predominantly Hyperactive-Impulsive Type (314.01) must have six or more of the following symptoms:
Often fidgets with hands or feet or squirms in seat;Often leaves seat in classroom;Often runs about or climbs excessively (For adolescents or adults, may be limited to feelings of restlessness);
Often has difficulty playing quietly;
Often blurts out answers to questions too soon;
Often has difficulty waiting in line or waiting for turn.
Often blurts out answers before questions have been finished.
Often has trouble waiting one’s turn.
Often interrupts or intrudes on others (butts into conversations or games).
Slide15ADHD- Combined and NOS IIIThe Combined Type (314.01) has both inattentive and hyperactive/impulsive symptoms. ADHD Not Otherwise Specified (314.9)
Adults and adolescents with ADHD who do not meet criteria for 314.0 or 314.01, but are affected by symptoms of ADHD
Slide16Diagnostic Requirements for ADHDThere must be the necessary number of symptoms from the lists above, andEach of the following criteria must be met:
The onset of symptoms is no later than seven years of ageThe symptoms must be present in two or more situations
(like home and school);
There must be clinically significant distress or impairment in social, academic, or occupational functioning;
The condition can not be caused by another psychiatric illness like Pervasive Developmental Disorder, Schizophrenia, or other psychotic disorder of mood, anxiety, dissociation, or personality.
Slide17Limitations of DSM-IV category of ADHD I1. ADHD is a symptom-complex not a disorder- Multiple etiologies, treatments and prognoses
2. Diagnostic criteria are behavioral and subjective3. Impairment is subjectively determined
Slide18Limitations of DSM-IV category of ADHD II4. Symptoms are situation specific, age-linked, and culture bound 5. Symptoms often become manifested after age 7
6. ADHD is confusing
Slide19Limitations of DSM IV Category of ADHD III7. Ability to “hyperfocus” is not addressed8. Traumatic Brain Injury (TBI) not explicitly
excluded9. Absence of “executive functions” in
symptom-complex
10.Must consider the manner in which symptoms may manifest in girls versus boys
Slide20Executive Functions INecessary for effective planning and problem solving Identify and prioritize problems Select, retrieve and /or gather, and organize pertinent data
3. Select an appropriate problem solving strategy4. Organize, analyze, and interpret relevant data5. Evaluate results and process
6. Working memory
Slide21Executive Functions II Focusing and filtering (in and out--selective attention)8. Affect regulation
9. Behavior regulation (e.g., impulse control)10. Regulate arousal level
11. Regulation information processing
12. Maintain motivation
Slide22What do these all have in common? Depression Oppositional defiant disorder Anxiety Learning disability Tourettes syndrome Poor social history Toxins (e.g.: lead poisoning) Poor hearing
Auditory processing problems Sleep problems Language disorder Physical or sexual abuse Post-Traumatic Stress Disorder Executive dysfunction
Head injury Neurological disorders
Intellectual precocity/impairment Family style
Sensory anomalies Poor school “fit”
Medications Dementias
Hearing loss Visual impairment
Etc.
Slide23They are all mistaken for ADHD
Slide24Causes of the ADHD Symptom Complex INormal (including “Active Alert”)General Medical problemsNeurological problems (other than ADHD)
Sensory deficits and hypersensitivitiesTraumatic Brain Injuries (TBI)Intellectual impairment (and precocity)
Learning disabilities
Dementias
Sleep disorders
Seizures
Medications
Slide25Causes of ADHD Symptom Complex IIFamily style and organizationSchool readiness, learning style, and motivationStress
Slide26Causes of ADHD Symptom Complex IIIPsychiatric conditions Substance use, abuse and withdrawal Anxiety Depression
Bi-Polar Behavioral disorders: Conduct Disorder, ODD Malingering
Pervasive Developmental Disorders
ADHD
4-5% of adults
9.5% of children
Slide27Response Time Histogram Comparison
Slide28Diagnosing ADHD IHistoryBehavior ratingsACTeRS, SBCL, BASC-2, BAADS, CTRS-R, Vanderbilt
Symptom behavior check list
4. Mental Status Exam
Continuous performance tests (CPTs)
Slide29Diagnosing ADHD II6. Physical and neurological exams 7. Psychological, psychiatric, and neuropsychological evaluations
8. Evaluation of classroom/work place
Slide30Comorbidity is the rule, not the exception58% - 87% of children diagnosed with ADHD have at least one comorbid disorderUp to 20% may have three or more comorbid disordersMost common comorbid conditions:
Oppositional Defiant Disorder (54% to 84%)Learning Disability or Language Disorder (25% to 35%)Anxiety disorder (up to 30%) – up to 50% have some symptomsMood disorder (up to 33%)
Substance Abuse (ADHD 5-10x more common in adult alcoholics than non-alcoholics)
Slide31Co-morbidity by Type IPredominantly Inattentive Type:21% had Oppositional Defiant Disorder21% had Minor Depression Dysthymia Disorder19% had Generalized Anxiety Disorder
Slide32Co-morbidity by Type IIPredominantly Hyperactive-Impulsive Type:42% had Oppositional Defiant Disorder22% had Generalized Anxiety Disorder19% had Minor Depression Dysthymia Disorder
Slide33Co-morbidity by Type IIICombined Type:50.7% had Oppositional Defiance Disorder22.7% had Minor Depression Dysthymia Disorder12.4% had Generalized Anxiety Disorder
Slide3434
ADHD vs. Pediatric Bipolar Disorder?
PBD is certainly over diagnosed
50% diagnosed were PBD reclassified as depression or conduct disorder when given research-based assessment
Many symptoms are misinterpreted:
Social “activation” in ADHD
“Explosive” behavior in ODD
“Mood swings” loose term, can have multiple causes
“Episodes” can be secondary to stressors
Sexual precocity can arise from sexual abuse or exposure to pornography
Slide35Treatment of ADHD IEstablish diagnosis and provide informationPsychotherapy: Parental/Spousal counseling, school/workplace, vocational, recreationalCoaching
Slide36Treating ADHD IINeurofeedbackBehavior modificationDietary considerations
MeditationMedication
Slide37Measuring Symptoms and TreatmentSubjective measuresReports and historyBehavior ratingsSymptom checklistsGlobal clinical judgment
Objective measuresPsychological and educational testsCPTs
Slide38Medication Dosage Effects on Attention and Behaviour (Schematic)
Slide39Continuous Performance Tests (CPTs) CPTs measure how well a person pays attention by continuously monitoring how quickly and successfully a task is performed over time.
Slide40T.O.V.A.®Tests of Variables of AttentionThe Visual T.O.V.A. measures attention, impulsivity, reaction time and consistency when processing visual
informationThe Auditory T.O.V.A.. measures attention, impulsivity, reaction time and consistency when processing auditory information
Slide41Slide42Slide43Visual Stimuli: Focus Point
.
Slide44Visual Stimuli: Nontarget
Slide45Visual Stimuli: Target
Slide46Visual Practice Test
Slide47Auditory StimuliTarget: G above Middle C (392.0 Hz)Nontarget: Middle C (261.6 Hz)
Slide48Auditory Practice Test
Slide49T.O.V.A. Test Construction
Fixed 2 second intervals between stimuli
Stimulus “on” for 1/10 second (100 ms)
There are two subtests
In half 1 (the "
Infrequent
" or vigilance test) the
target-to-nontarget ratio is 1:3.5
In half 2 (the "
Frequent
" or high response test) the
target-to-nontarget ratio is 3.5:1
Length of test
10.8 minutes for each subtest, 21.6 minutes total for 6 and older
Thus 21.6 minutes for entire test
“Sufficiently long” for measuring attention
5.4 minutes each subtest, 10.8 minutes total for ages 4-5,
Slide50T.O.V.A. Test Features IResearch-quality time measurement (1 ms)Real time measurement
Slide51Preset Mean Standard Exact Measured DeviationSoftware/ Response Response MeasuredInput Device Time Time Response (ms) (ms) (ms)
T.O.V.A.™ Microswitch 300 300 ±1 600 599 ±1
Conners' with Mouse 300 353 +28
600 655 +14
900 943 +21
Conners' with Keyboard 300 355 +28
600 656 +11
900 948 +25
Timing Accuracy of CPTs
Slide52T.O.V.A. Test Features IIMonochromaticNonsequentialNon-alphanumericCulture free
Slide53T.O.V.A. Test Features IIIFixed intervalsVisual or auditoryLimited practice effects (high test-retest reliability)Extensive age and gender based norms from 4-80+
Symptom Exaggeration Index
Slide54T.O.V.A. Variables IResponse Time Variabilityprocessing time inconsistencyCorrect Response Time
processing timed' or Response Sensitivitydecrement of performance in differentiating signals (targets) from noise (nontargets)
Slide55T.O.V.A. Variables IIErrors of Commissionresponding incorrectly to a nontarget; a measure of impulsivity and/or disinhibitionErrors of Omission
not responding to a target; a measure of inattention
Slide56T.O.V.A. Variables IIIAnticipatory Responsesresponding <150 ms after stimulus; a measure of guessingPost-Commission Response TimeResponse Time following a Commission Error; self control measure
Multiple Responsesmore than one response per stimulus; a reflection of neurological status and/or test taking behavior
Commission Error Response Time
Response time when making a commission error
Slide57Norms
Standard Deviation of Response Time (ms)
Age
Variability (SD, ms): Total Test – Females
[Mean
+
SD]
Slide58The T.O.V.A. does not diagnose ADHD
Slide59The T.O.V.A. measures attention, impulsivity, reaction time and consistency.
Slide60Uses of the T.O.V.A. IScreen children and adults for attention problems Establish baseline for tracking attention problems over time
Slide61Uses of the T.O.V.A. IVMonitor treatment
Slide62Monitoring Treatment Over Time
(Illustration 1)
Slide63Monitoring Treatment Over Time(Illustration 2)
Slide64Uses of the TOVA V
Measure effectiveness of medication throughout the day
Slide65Test InformationRequired InformationGroup ID, Subject ID and Session # (automatically generated)Date and Time of Test (automatically entered)Date of Birth
GenderMedication and dosage informationCustom Subject FieldsOptional Information
Subject name
Test administrator’s name
Comments
Slide66Guidelines for T.O.V.A. AdministrationAdministered first and only in the mornings
Slide67Guidelines for T.O.V.A. Administration IITesting room should be quiet with no distracting noises and with dim lightsAn observer must be present at all times
When testing for first time, the entire practice test should be given Do not prompt unless absolutely necessary
Slide68Guidelines for T.O.V.A. Administration III Use the T.O.V.A. Rating Form
Slide69Slide70Guidelines for T.O.V.A. Administration IV Record use of caffeinated beverages and nicotine Record sleep in the night before testing
Slide71Guidelines for T.O.V.A. Administration V Allow 1.5 hours of rest between T.O.V.A. tests.
Slide72GUIDELINES FOR T.O.V.A. ADMINISTRATION 6 Compare Visual and Auditory T.O.V.A.’s for a more comprehensive assessment.
Slide73T.O.V.A. InterpretationClinical reports use clinical wording:The results are within normal limits.Overall, this T.O.V.A. is suggestive of an attention problem.
Screening reports avoid any diagnostic statement that could become a liability problem for non-clinicians, non-mental health professionals, and schools using the T.O.V.A.:The results are within normal limits.The results are not within normal limits and warrant a referral to a clinician for a clinical assessment.
Slide74T.O.V.A. InterpretationTHE T.O.V.A. DOES NOT DIAGNOSE ADHD:“Suggestive of an attention problem” does not necessarily mean that the person has ADHD.It simply means that the results were not within normal limits for age, gender, and assuming average intelligence.The T.O.V.A. Interpretation and the Attention Performance Index (API) are two separate interpretations of the data
These test results are not within normal limits, and the API (-2.18) is also not within normal limits.An API "within normal limits" is considered "inconclusive”. The subject may have an attention problem (including ADHD) but does not have the typical ADHD pattern.
Slide75This page is included in a Standard T.O.V.A. Report and in the Detailed T.O.V.A. Report
Slide76This page is included in a Standard T.O.V.A. Report and in the Detailed T.O.V.A. Report
Slide77This page is included in a Standard T.O.V.A. Report and in the Detailed T.O.V.A. Report
Slide78This page is included in a Standard T.O.V.A. Report and in the Detailed T.O.V.A. Report
Slide79Slide80This page is included in a Standard T.O.V.A. Report and in the Detailed T.O.V.A. Report
Slide81This page is included in the Detailed T.O.V.A. Report
Slide82This page is included in the Detailed T.O.V.A. Report
Slide83This page is included in a Standard T.O.V.A. Report and in the Detailed T.O.V.A. Report
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